Labour of love: the demise of traditional midwifery

Women-centred maternity care through midwifery is in danger of extinction, replaced by a medical model that treats birth as an illness. Birth is an act of love, not one of fear and loathing, so what are the consequences? Matilda Lee reports

‘I never imagined it would be a torture chamber', Ina May Gaskin says. ‘The instruments of torture were both psychological and physical.' At 26, she gave birth to her first child, but childbirth was an experience that made her feel ‘mistreated'.

‘I thought the doctor would be proud that I decided to go without anesthesia. Instead, he told me that in not doing so, my baby could get brain damage.' Her baby was born using forceps, instruments needed because, as the doctor told her, the baby is like a ‘battering ram against a hard perineum'.

Today, Ina May Gaskin is one of the most famous midwives in the world, recognized for her outspoken defence of the profession she says is 'in danger of extinction'.

‘People no longer understand that our bodies are as well designed as the other 5,000 mammals that give birth to live offspring,' Ina May says. ‘I teach people to search out the chimpanzee that lives within you. Forget about what people say about childbirth. If a chimpanzee can do it, so can you.'

At the birth centre she founded at the eco-community, ‘the Farm' in rural Tennessee, Ina May and her small team of midwives have delivered over 3,000 babies in the last 40 years. Less than 2 per cent of women who give birth at ‘the Farm' end up delivering by caesarian [compared with a rate of 34 per cent in the US as a whole].

She's delivered nearly 100 breech babies and over 20 sets of twins - all without complications, interventions or pain relief. But ask what her secret is and she just shrugs - she is only helping women do what comes naturally.

Birth after birth, Ina May has witnessed women go through the hugely empowering, transformative, life-changing event that is childbirth. But Ina May is one of a dying breed of traditional midwives in industrialised countries. Traditional midwifery is actually banned in some states in the US, while many face persecution. The most widespread trend is the denigration of the midwives' skills and expertise as a medical model of birth has taken hold.

UK midwifery care under threat

UK midwifery is undergoing a crisis in numbers and identity. The decline in one-on-one care for women before, during and after labour has had a number of profound implications including a rising number of interventions in birth, an increase in caesarian sections and declining rates of breastfeeding.

The birth rate in England climbed steadily by 15 per cent between 2001 and 2010 , with predictions for a further five per cent rise over the next five years. Cathy Warwick, General Secretary of the Royal College of Midwives has lodged a petition with Parliament calling on the Government to recruit an extra 5,000 midwives into the NHS in England to fill a ‘desperate shortfall'. Since 2010, there have been another 896 new midwives, - to add to a total of 21,000 - but the number of births in England are expected to climb from 687,007 this year to 723,000 by 2014-15.

‘Our argument is that the work has increased to such an extent now that midwives really can't offer the highest quality care that women in this country should certainly be able to expect. That matters because there is now an increasing body of evidence that indicates that aspects of care which midwives specifically offer are really important to high quality outcomes,' she says.

Mind the gap

It's a vicious cycle. The gap in good maternity care leads to higher rates of caesarian births, which weighs more on the NHS -costing an average of £1,701 while a vaginal delivery averages less than half that at £749. The drain on funds leads to fewer resources for good midwifery care. All this has happened in a shockingly short span of time: in 1990, the C-section rate in England was 12 per cent, but by 2005 it had doubled to 24 per cent. Each 1 per cent rise in Caesarean section rates costs the NHS £5m per year.

Sarah Montagu, admin secretary at the Association of Radical Midwives (ARM) and a practicing independent midwife, says the decline in maternity services is most stark in post-natal care. ‘It used to be standard to have daily midwife visits in the first ten days after a woman gave birth. It's gone from that to, in some places, one visit from the midwife before she discharges on the 10th day. That leads to huge problems with breastfeeding.'

‘Probably the things that most "Mumsnetters" would agree on is that no matter how much you plan, birth doesn't always end up as you wanted it,' says Katie O'Donovan, Head of Communications at Mumsnet, the hugely popular UK parenting forum which attracts 2 million visitors each month. ‘But for "Mumsnetters", one of the most common experiences is having suffered through bad post-natal care. The view is pretty unanimous from people who have experienced a couple nights in hospital after giving birth. Insufficient post-natal care leads to real problems for new mums'.

Hospital vs. home births

But the dearth in numbers is only half the story of today's midwives. They also face a diminished role in maternity care that is dominated by the ‘medical model'. Today, around 90 per cent of births in the UK take place in hospitals. Although, even in the hospital system, midwives look after the majority of women, very frequently doctors are working alongside midwives, shifting the philosophy of childbirth from one that aims to enhance normality and reduce interventions to one that is predicated on birth being normal only in retrospect.

With doctors working alongside midwives, anesthetists come into the equation, and epidurals ‘on demand' to control pain, have played a significant part in changing the whole approach. Technologies such as electronic foetal monitoring during labour, and induced labour for women over 42 weeks pregnant have all combined together to create a much more medical model of childbirth.

The medical model has brought about a transformation in the idea of safety and risk.

‘We need to be practising safe care. But the question is, safe for whom?' says Sarah Montagu. ‘Now, it is more about the safety of the institution rather than the individual. For a small number of women, the placenta acts less efficiently after 42 weeks of pregnancy. But there is now an assumption that all women should be induced if they are 10 days past their due date. If a woman is not physiologically ready, this leads to a cascade of interventions starting with hormones to get the cervix to respond and ending with high caesarian rates. When I started midwifery, the C-section rate was 9 - 10 per cent, now it is more than double that. Induction has played a large part in that. So has the fear of litigation.'

A labour of love

‘We are completely lost. We have even forgotten to raise the most simple questions. What are the basic needs of women in labour? The fact that midwives have disappeared is a symptom of the lack of understanding of the basic needs of women in labour,' says Michel Odent, one of the world's foremost proponents of natural birth. ‘The best thing to do is to go back to square one. The point of departure'.

The point of departure is the realisation that childbirth is an act of love. Literally. Odent refers to a ‘complex cocktail of love hormones' that are released by a mother when a baby is being born. ‘Mother and baby are under the influence of a sort of morphine, a natural opiate. Women, like all other mammals, are supposed to release this as soon as the baby is born. Today, most women give birth without releasing these hormones'.

Ina May says, ‘the first women I took care of were afraid of hospitals. In being able to give birth at home they were grateful, and in a grateful state of mind, it so happens that the right hormones are there. You have natural oxytocin, and you have endorphins. You also have adrenaline, from fear, which is in direct opposition to oxytocin. If you have pain, your oxytocin is down, which means sometimes your labour can reverse itself. Your body can close. Or you get a really painful labour because you have no endorphins. Then you get more scared and the pain gets worse. You are then in a bad cycle. But if somebody could just come in and help you calm down, right away it can just happen. That's how it works but people don't know that. A woman can be terrified of childbirth, but with a little encouragement, the pain can go.'

What a woman needs in labour is confidence and support and throughout history midwives have filled that role, guiding women towards this intangible essence of bliss. When labour's love is lost, we're left with fear. The cost of medicalised birth is more than we should be asked to bare.

Neighbourhood Midwives

Annie Francis wants to start a revolution in midwifery care in the UK. This June, she and a small group of six midwives will begin piloting a new scheme of community-based caseload midwifery care. The group she created, Neighbourhood Midwives, will offer a win-win solution for NHS's overstretched maternity services. As an employee-owned social enterprise, Neighbourhood Midwives will offer women one-on-one care with a local midwife, who they can get to know and trust and who will offer them the choice of where to give birth. She says so far they've had 1,000 midwives express interest in joining them.

‘NHS maternity care is a fragmented, dysfunctional system. We've taken one of life's crucial events and institutionalised it. Women have to be in the right place in their heads when they give birth. If midwives can get back into the community, the fear factor will break down.'